report from the technical committees & tiger teams documents/standards... · 2015. 9. 23. ·...

0HITSP – enabling healthcare interoperability

Report from the Technical Committees & Tiger Teams

Arlington, VA | January 25, 2010

Presented by:

Joyce Sensmeier MS, RN-BC, CPHIMS, FHIMSS &

HITSP Technical Committee & Tiger Team Co-Chairs

enabling healthcare interoperability

Document Number: HITSP 10 N 456

Date: January 25, 2010


Current Work Items 2009/10

General Lab Orders

Order Sets

Long Term Care Assessment

Provider Consumer Population

Admin/Finance

Care Management/ Health Records

Scheduling

Prior-Authorization in Support of

Treatment, Payment, & Operations

Common Device Connectivity

Medical Home: Co-morbidity and Registries

Medication Gaps

Clinical Note Details

Data Architecture

Newborn Screening

Maternal/Child Health

Consumer Adverse Event Reporting

Quality Measures

Clinical Research

Consumer Preferences(shared with Consumer)

Common Data Transport

Security/Privacy/ Infrastructure


Technical Committee LeadershipPopulation Perspective - 382 members– Floyd P. Eisenberg, MD, MPH, National Quality

Forum

– Eileen Koski, M. Phil, Medco Health Solutions, Inc.

– Anna Orlova, PhD, Public Health Data Standards Consortium

Consumer Perspective – 231 members– Mureen Allen, MD, FACP, ActiveHealth Management

– Charles Parisot, EHR Association

– Scott Robertson, PharmD, Kaiser Permanente


Technical Committee LeadershipProvider Perspective – 265 members– Allen Hobbs, PhD, Kaiser Permanente

– Steve Hufnagel, PhD, DoD/Medical Health System (MHS)

– Mike Lincoln, MD, Department of Veterans Affairs

Security, Privacy & Infrastructure Domain -347 members– Glen Marshall, Grok-A-Lot, LLC

– John Moehrke, GE Healthcare

– Walter Suarez, MD, Kaiser Permanente


Technical Committee LeadershipCare Management and Health Records Domain - 228 members– Keith Boone, GE Healthcare

– Corey Spears, McKesson Health Solutions

– Greg Alexander, PhD, RN, Alliance for Nursing Informatics

Administrative and Financial Domain – 85 members– Don Bechtel, Siemens Medical Solutions

– Durwin Day, Health Care Service Corporation

– Manick Rajendran, eZe Care LLC


Tiger Team LeadershipClinical Research – 147 members– Walter Suarez, MD, Kaiser Permanente

Data Architecture – 159 members– Keith Boone, GE Healthcare

– Teresa Strickland - National Council for Prescription Drug Programs

Quality Measures – 123 members– Floyd P. Eisenberg, MD, MPH, National Quality Forum

– Eileen Koski, M. Phil, Medco Health Solutions, Inc.

Consumer Preferences – 142 members– Walter Suarez, MD, Kaiser Permanente

– Mureen Allen, MD, FACP, ActiveHealth Management

Technical Committee/Tiger Team Membership 914 individuals


Year # of Volunteer Hours

2007 12,0002008 19,0002009 23,730

The “HITSP Nation”Powered by 54,730 Hours in 3 years!!

HITSP NATION

HITSP eTown Hall January 22, 2010


Report from theConsumer Perspective Technical Committee

Year-end Work Summary– CPTC deliverables submitted for Panel approval

– Additional deliverables finalized for 31-Jan-2010


CAP117 - Communicate Ambulatory and Long Term Care Prescription

CAP118 - Communicate Hospital Prescription

CAP119 - Communicate Structured Document

CAP120 - Communicate Unstructured Document

TN905 – Device Connectivity

IS03 – Consumer Empowerment and Access to Clinical Information via Networks

IS05 – Consumer Empowerment and Access to Clinical Information via Media

IS12 – Patient-Provider Secure Messaging

IS77 – Remote Monitoring

IS98 – Medical Home

IS07 – Medication Management (incl. Medication Gaps extension)


CPTC Deliverables

Recognized / Panel ApprovedSubmitted for Panel Approval

Additional Deliverables



Key Capabilities: Addresses interoperability requirements that support electronic prescribing in the ambulatory and long term care environment. The capability supports: • Transmittal of new or modified prescriptions • Transmittal of prescription refills and renewals • Communication of dispensing status • Request for Benefit Eligibility Determination

Selected Standard(s): Accredited Standards Committee (ASC) X12 270 and 271 Transaction Standards Version 4010, using the Insurance Subcommittee (X12N) Addenda 004010X92A1; National Council for Prescription Drug Programs (NCPDP) SCRIPT Standard Implementation Guide Version 8.1 or 10.1; Centers for Medicare and Medicaid Services (CMS) National Provider Identifier (NPI); Drug Enforcement Administration (DEA) Prescriber Number; National Library of Medicine (NLM) Unified Medical Language System (UMLS) RxNorm

Used by: HITSP/IS07 V:1.1 Medication Management

Deliverables Submitted for Panel ApprovalHITSP/CAP117 - Communicate Ambulatory and Long

Term Care Prescription



Key Capabilities: Addresses interoperability requirements that support electronic prescribing for inpatient orders that can occur within an organization or between organizations. The capability supports the transmittal of a new or modified prescription from a Hospital to an internal or external pharmacy. It also includes the optionality to access formulary and benefit information.

Selected Standard(s): Accredited Standards Committee (ASC) X12 270 and 271 Transaction Standards Version 4010, using the Insurance Subcommittee (X12N) Addenda 004010X92A1; Health Level Seven (HL7) Version 2.5/2.5.1 –Pharmacy/Treatment Orders (OMP); National Council for Prescription Drug Programs (NCPDP) SCRIPT Standard Implementation Guide Version 8.1 or 10.1; Centers for Medicare and Medicaid Services (CMS) National Provider Identifier (NPI); Drug Enforcement Administration (DEA) Prescriber Number; National Library of Medicine (NLM) Unified Medical Language System (UMLS) RxNorm

Used by: HITSP/IS07 V:1.1 Medication Management

Deliverables Submitted for Panel ApprovalHITSP/CAP118 - Communicate Hospital Prescription



Key Capabilities: addresses interoperability requirements that support the communication of structured health data related to a patient in a context determined by the author of the document. This Capability supports the exchange of all CDA documents. The following are examples of the type of CDA structured data that are supported: • Continuity of Care Document (CCD) • Emergency Department Encounter Summary • Discharge Summary (In-patient encounter and/or episodes of care) •Referral Summary Ambulatory encounter and/or episodes of care • Consultation Notes • History and Physical • Personal Health Device Monitoring Document • Healthcare Associated Infection (HAI) Report Document

Orchestrates:

Any CDA document using HITSP/C83 - CDA Content Modules

HITSP/SC112 – Healthcare Document Management

Deliverables Submitted for Panel ApprovalHITSP/CAP119 - Communicate Structured Document



Key Capabilities: Addresses interoperability requirements that support the communication of a set of unstructured health data related to a patient in a context set by the source of the document who is attesting to its content. Two types of specific unstructured content are supported, both with a structured CDA header: • PDF-A supporting long-term archival • UTF-8 text

Orchestrates:

HITSP/C62 – Unstructured Document

HITSP/SC112 – Healthcare Document Management

Deliverables Submitted for Panel ApprovalHITSP/CAP120 - Communicate Unstructured Document



Objective: Intended to act as a framing document to provide a high-level perspective on device connectivity requirements, to propose a roadmap for how ONC/HITSP might address these requirements, and to indicate how it might work with other external organizations to resolve standardization gaps. The specific requirements to be addressed in the roadmap pertain to device-related elements in currently available standards-based device connectivity technical specifications leading up to the harmonization requests assigned to HITSP as identified in the Common Device Connectivity (CDC) Extension/Gap from AHIC in December, 2008.

Key Components: Medical Device Connectivity Topology, Device Intermediary Deployment, Data Timing Characteristics, Device Integration with Clinical Applications, Support for Clinical Decision Support, Highly Integrated Patient-centric Point-of-Care, Regulatory Considerations

Potential Capabilities and Constructs: Patient-Device Association; Device Data Reporting/Integration with EHRs; Alarm and Alert Communication; Device Semantic Content; Real-time Location Tracking

Deliverables Submitted for Panel ApprovalHITSP/TN905 - Device Connectivity



Progress on IS77: Remote Monitoring The AHIC Remote Monitoring Use Case resulted in the approval of IS77 in December 2008 with a Gap for harmonizing standards for the transaction between the Home Hub and the Remote Monitoring Management System.

IHE Patient Care Devices and Continua were engaged in co-developing a consistent approach that meets, with the same set of standards, the needs of:

Wide-Area Exchange of Home Health Monitoring Device Information

In-Patient Monitoring Device Information

This is a major accomplishment that ensures consistent standards and mixed deployment models in the consumer home (combined home hospitalization and home health)

These profiles and implementation guidelines are scheduled to be formally approved by IHE PCD and Continua later in Q1 2010. The update of IS77 to include the HITSP/T73 Aggregated Device Information Communication construct addressing the aforementioned Gap will be possible for 2Q 2010 (next HITSP work cycle).

Remote Monitoring Device Connectivity



HITSP/IS98 – Medical HomeKey Capabilities: addresses the interoperability requirements to support the following scenarios: 1. the ability to manage patient problem lists, and 2. the ability to perform practice-based, population management, and registry functions for care coordination to support patient needs, clinical decision support, and quality reporting. IS98 leverages the ability for the MH provider to extract and use the problem list from structured documents. In addition, it leverages a number of existing HITSP constructs to facilitate a practice’s population view of subsets of patients.

Selected Standard(s): N/A

References: HITSP/CAP119 Communicate Structured DocumentHITSP/CAP120 Cummunicate Unstructured DocumentHITSP/CAP123 Retrieve Existing Data HITSP/CAP127 Communicate Lab Results DocumentHITSP/CAP128 Communicate Imaging Information HITSP/CAP129 Communicate Quality Measure Data HITSP/CAP130 Communicate Quality MeasureHITSP/CAP135 Retrieve and Populate Form HITSP/CAP143 Manage Consumer Preferences and Consents



Key Capabilities: Describes the information flows, issues and system capabilities that apply to the multiple organizations participating in medication management. It is intended to facilitate access to necessary medication and allergy information for consumers, clinicians, pharmacists, health insurance agencies, inpatient and ambulatory care, etc.

Selected Standard(s): N/A

References: HITSP/CAP117 Communicate Ambulatory and Long Term Care PrescriptionHITSP/CAP118 Communicate Hospital PrescriptionHITSP/CAP119 Communicate Structured DocumentHITSP/CAP120 Communicate Unstructured DocumentHITSP/CAP140 Communicate Benefits and EligibilityHITSP/CAP141 Communicate Referral AuthorizationHITSP/CAP143 Manage Consumer Preferences and Consents

Additional DeliverablesHITSP/IS07 – Medication Management (v2)



ConclusionRe-organization of constructs to use generalized Capabilities will promote re-use and consistency.

Continue to re-use and modify existing constructs where possible to meet new use case requirements and add new constructs where required.

Continued inclusion of medical devices information into the home, ambulatory and acute care interoperability use cases

Continued expansion and refinement of existing constructs to fill gaps or specific areas of interest.

Continue to have a great amount of work and looking for additional members to assist.


HITSPQuality Tiger Team

Quality Interoperability Specification3.2 Capability Orchestration

3.2.2 Implementation variants – 6 options for interoperability architecture

3.2.2 Constraints updates

4.0 Capability Gaps – updates

4.1 Standards Overlaps – updates



Quality Interoperability SpecificationArchitecture-neutral interoperability – variants reviewed


HITSPQuality Tiger TeamNEW Items since last panel review

Capability 129: Communicate Quality Measure Data Capability

Capability 130: Communicate Quality Measure Specification

C105: Patient Level Quality Data Document Using HL7 Quality Reporting Document Architecture

C106: Measurement Criteria Document

C154: HITSP Data Dictionary

Quality Dictionary Section (Table 2.45)

TN 906: Quality Measures Technical Note

Specification for all 16 measure exemplars completed, including QRDAs(C105)


Service Collaboration and Components

Capabilities

CAP119: Communicate Structured DocumentCAP119: Communicate Structured Document

Constructs as needed by the SCe.g. TP20, T15, T16, T17




Constructs as needed by the CAPe.g. C105, SC129, SC130

Constructs as needed by the CAPe.g. C105, SC129, SC130

CAP122: Retrieve Medical KnowledgeCAP122: Retrieve Medical Knowledge

CAP129: Communicate Quality Measure DataCAP129: Communicate Quality Measure Data

CAP135: Retrieve and Populate Form

CAP135: Retrieve and Populate Form

CAP123: Retrieve Existing DataCAP123: Retrieve Existing Data

CAP138: Retrieve PseudonymCAP138: Retrieve PseudonymCAP130: Communicate Quality Measure

SpecificationCAP130: Communicate Quality Measure

Specification

Capabilities Used in IS06 Update

IS06 Quality



SPI Service Collaborations in IS06 Update

Quality IS CapabilitiesQuality IS Capabilities

Constructs Specified in Service Collaborations

Service Collaborations

SC108:Access ControlSC108:Access Control

Transactions, Transaction Packagesas needed by the SCe.g. TP20, T15, T16, T17

Transactions, Transaction Packagesas needed by the SCe.g. TP20, T15, T16, T17

SC112:Healthcare DocumentManagement

SC112:Healthcare DocumentManagement

SC110:Patient Identification Management

SC110:Patient Identification Management

SC111:Knowledge And Vocabulary

SC111:Knowledge And Vocabulary

SC109:Security AuditSC109:Security Audit

SC113:Query forExisting Data

SC113:Query forExisting Data

SC115:HL7 MessagingSC115:HL7 Messaging

Components(C25, C26,C28, C32, C34, C48, C80, C83, C105, C106, C154)

Components(C25, C26,C28, C32, C34, C48, C80, C83, C105, C106, C154)

IS documents/Workflows



HITSPQuality Tiger TeamIS06

• Updates and clarifications post-HITSP Panel

• Clarification of supporting UML diagrams

• Addition of UML diagram descriptions

• Clarification of variant diagrams and descriptions


HITSPQuality Tiger TeamC105 – Patient Level Quality Component

Using HL7 Quality Report Document Architecture (QRDA)


HITSPQuality Tiger TeamC106 – Measurement Criteria Component

• References HL7 eMeasurerepresentation of Healthcare Quality Measure Format (HQMF)

• DSTU status November 4, 2009


HITSPQuality Tiger TeamTN 906

• 16 ‘re-tooled’ measures

• Venous Thromboembolism (VTE)

• Stroke (STK)

• Emergency Department (ED) Throughput


HITSPQuality Tiger TeamTN 906

• Re-tooling

Data element

Intended meaning with respect to the measure

Clinical usage Chart abstraction

Electronic clinical record data

Work with original measure developer (steward)

Single context (location)Standard vocabulary

CDA chapterValue set



TN 906

• Updates and clarifications post-HITSP Panel

• Section 2.2.1 General Observations –move to introduction

• Updates to Table 2-17 General Measure Retooling Issues and Recommendations

• Updates to Table 2-18 Measure Element Changes in Support of Electronic Specification - Specific change log for individual items within the 16 measure exemplars

• Add Measure flow diagrams from The Joint Commission

• Updates to eMeasure sample XML (C106)


Report from the Population Perspective Technical Committee

Newborn Screening Use Case - ScenariosOrdering and Resulting: This scenario covers initial screening both for Newborn Dried Blood Spot (NDBS) and Early Hearing Detection and Intervention (EHDI) and ends with the reporting of results, either within normal limits, or notification of the need for confirmatory testing if results are outside of normal limits.

Abnormal and Out of Range Results: This scenario covers the processes in response to an out of range (or abnormal) screening test either from the NDBS or the EHDI.


Service Collaboration and Components

Capabilities

CAP 120 Communicate Unstructured DocumentCAP 120 Communicate Unstructured Document





Constructs as needed by the CAPe.g. C152, C161, C163

Constructs as needed by the CAPe.g. C152, C161, C163

CAP 121 Communicate Clinical Referral RequestCAP 121 Communicate Clinical Referral Request

CAP 119 Communicate Structured DocumentCAP 119 Communicate Structured Document

CAP135 - Retrieve and Populate FormCAP135 - Retrieve and Populate Form

CAP123 - Retrieve Existing DataCAP123 - Retrieve Existing Data

CAP138 - Retrieve PseudonymCAP138 - Retrieve Pseudonym

CAP 99 HITSP Communicate Lab Order MessageCAP 99 HITSP Communicate Lab Order Message

Capabilities Used in IS92 IS92 Newborn Screening

HITSPPopulation Perspective TC

122 Retrieve Medical Knowledge 122 Retrieve Medical Knowledge

CAP 127 Communicate Lab ResultsCAP 127 Communicate Lab ResultsCAP 126 Communicate Lab Results MessageCAP 126 Communicate Lab Results Message

CAP 143 Manage Consumer Preference and ConsentsCAP 143 Manage Consumer Preference and Consents

CAP 142 Retrieve Communications RecipientCAP 142 Retrieve Communications Recipient


Report from the Population Perspective Technical CommitteeNewborn Screening IS92Newborn Bloodspot Testing

NBS Lab Order – IS Constrains HITSP/CAP99 Communicate Lab Order Message

– HITSP/C163 - Laboratory Order– Constrained to use Newborn Screening Vocabularies– Support for Pediatric Demographics

NBS: pre-populate form from Birthing Summary (printing order on the specimen card) - IS Constrains HITSP/CAP135 Retrieve and Populate Form to pre-populate from:

– HITSP/C161- Antepartum Record– HITSP/C152- Labor and Delivery Report

Lab Result : HITSP/CAP126 Communicate Lab Results Message, HITSP/CAP 127 Communicate Lab Results

– IS Constrains HITSP/C126 Communicate Lab Results Message– IS Constrains HITSP/C127 Communicate Lab Results– Constrained to use Newborn Screening Vocabularies


Report from the Population Perspective Technical CommitteeNewborn Screening IS92 – Content (continued)Hearing Screening

Hearing Screening Test Result – IS Constrains HITSP/C126 Communicate Lab Results Message– IS Constrains HITSP/C127 Communicate Lab Results– Constrained to use Newborn Screening Vocabularies– Support for Pediatric Demographics

Abnormal ResultsIS Constrains HITSP/CAP119 Communicate Structured Document

– CAP 119 Communicate Structured DocumentSupport for Pediatric DemographicsAdd support for HITSP/C161- Antepartum RecordAdd support for HITSP/C152- Labor and Delivery ReportConstrain to include screening results in newborn follow-up summaries

– CAP 120 Communicate Unstructured Document – CAP 121 Communicate Clinical Referral Request


Report from the Population Perspective Technical CommitteeNewborn Screening IS92 – Content (continued)Abnormal Results

CAP 119 Communicate Structured Document – Support for Pediatric Demographics– Add support for HITSP/C161- Antepartum Record– Add support for HITSP/C152- Labor and Delivery Report– Constrain to include screening results– Support for Notification and Subscription

CAP 120 Communicate Unstructured Document CAP 121 Communicate Clinical Referral Request

Guidelines and EducationCAP 122 Retrieve Medical Knowledge

Public Health ResearchC164 Anonymize Newborn Screening Data


Report from the Population Perspective Technical Committee

Maternal and Child Health – IS91 (Wave 2)

Interoperability Specification submitted to HITSP staff for technical & editorial review in preparation for public comments

Public Health Case Reporting – IS11 (Wave 3)

Updated Interoperability Specification including support for Consumer Adverse Event Reporting submitted to HITSP staff for technical & editorial review in preparation for public comments


Report from the Clinical Research Tiger Team

Value CaseWorkgroup developed initial draft detailed value case and extensions (Nov 2008 – Feb 2009)

Draft value case posted for public comment in March 2009

Detailed value case completed by end of April, 2009; value case submitted HITSP for development of interoperability specifications

Document describes three value scenarios:



Tiger Team work started May 14, 2009

Created under the sponsorship and oversight of the Population Perspective Technical Committee

To address to Clinical Research Use/Value Case presented to HITSP

Membership: 100+ joined the TT representing provider organizations, research institutions, federal/state public health government, national research associations and vendors; added a large number of new members to HITSP

Requirements Analysis completed (May-July, 2009)Incorporated new HITSP Framework concepts of Capabilities and Service Collaborations

Identified need for two additional constructs specific to Clinical Research, plus updates to selected existing constructs



Published RDSS for public comment (August, 2009)

Prepared a draft Clinical Research Interoperability Specification and two Clinical Research Constructs (September-October, 2010)

Prepared a draft Clinical Research Interoperability Specification and two Clinical Research Constructs (September-October, 2010)

HITSP/IS158 – Clinical Research Interoperability Specification

HITSP/C151 – Clinical Research Document Component Construct

HITSP/C156 – Clinical Research Workflow Component Construct

IS utilizes four main capabilities:HITSP/CAP127 – Communicate Lab Results Document

HITSP/CAP128 – Communicate Imaging Information

HITSP/CAP135 – Retrieve and Populate Form

HITSP/CAP143 – Manage Consumer Preference and Consents


Published IS and supporting Constructs for public comment (November-December, 2009)

Received 35 comments; completed resolution/disposition of comments by December 20; harmonized terminology used in the IS and Constructs and refined the use of capabilities in the IS

Completed HITSP Inspection Testing Process (December 4, 2009)

Offered a HITSP Webinar on Clinical Research IS/Constructs, in coordination with HITSP ECO (November 19, 2009)

Completed HITSP Inspectors Testing Process (December, 2009)

Completed internal editorial and quality review prior to publication (January, 2010)

Published final documents for Panel approval (January 18, 2010)



IS Scope and Overview

US realm only

Spans two industries, healthcare and clinical research, and incorporates standards from healthcare (HL7 and IHE) and research (CDISC).

Leverages the current players in the clinical research industry such as Electronic Data Capture (EDC) systems and research registries

Provides ability to communicate information about particular study participants: eligibility information, results, and case report form data


IS Scope and Overview

Allows the exchange of a core dataset of pseudonymized or anonymized information from the EHR to a research system for use in clinical research

Supports privacy and security needs

Covers core areas including:– Description of scenarios– Definition of Information Exchanges Requirements– Identification/Naming of System– Description and Orchestration of Capabilities Used– Identification of Constructs Needed– Identification of Gaps


Component 151 – Clinical Research Document

Describes the content and format to be used for pre-population data within the Retrieve Form Transaction (Cap 135)

Supports a standard set of data in the HL7 Continuity of Care Document (CCD) format which the RFD Form Filler provides for use in Clinical Research

Provides the ability to convert this output into a standard case report form (Standard CRF) based on the Clinical Data Acquisition Standards Harmonization (CDASH) specification and the Operational Data Modal (ODN) of Clinical Data Interchange Standards Consortium (CDISC).


Component 156 – Clinical Research Workflow

Purpose of Clinical Research Workflow is to support a standard set of data specific to research usage, as found in CDISC CDASH standard

Describes the Clinical Data Acquisition Standards Harmonization (CDASH) data elements and common identifier variables that pertain to the research-specific workflow.

Describes the data elements that allow the RFD system roles Form Filler and Form Manager to identify what needs to be done.

Reader must refer to HITSP/C154 – HITSP Data Dictionary for a mapping of the CDISC CDASH data


Capabilities Used in the IS

HITSP/CAP127 – Communicate Lab Results Document

– Communicates a set of structured laboratory results

HITSP/CAP128 – Communicate Imaging Information

– Communicates a set of imaging results

HITSP/CAP135 – Retrieve and Populate Form

– supports pre-population of information from the clinical or laboratory information systems to avoid manual re-entry

HITSP/CAP143 – Manage Consumer Preference and Consents

– Used to capture a patient or consumer agreement to one or more privacy policies


Identified Gap

The data sent from the EHR to the EDC must conform to the protocol. Currently there is a gap in the ability to redact the CCD to conform to the protocol-required data as specified in the case report form

Resolution:

– A new IHE profile called Redaction Services has been accepted for inclusion in the Quality, Research, and Public Health (QRPH) domain


Report from the Provider Perspective Technical Committee

2009 Work Items– CAP99 – Communicate Lab Order Message Capability,

up for approval

– CAP95 – Communicate Order Sets

– Extension to IS09 – Consultations and Transfers of Care to incorporate Long Term Care Assessments.


Report from the Provider Perspective Technical Committee – CAP99

In Scope for CAP99– Sending and receiving HL7 laboratory order, control and status

messages

– Orders may be from an inpatient or outpatient setting

– Provides a robust General Laboratory Order Capability between an Order Placer and an Order Filler



Out of scope– Robust treatment of repeating orders and the ability to discontinue

these orders

– Capabilities of an Order Management System

– Communicating thresholds for discontinuing a repeating order

– Rules that govern when a Filler can discontinue a repeating order without a request

– Tests on non-human specimens (E.g. Environmental testing, animal testing, etc)

– Workflows within the laboratory



System Roles– Order Placer: The application requesting a laboratory service or

laboratory observation

– Order Filler: The application providing a laboratory service orlaboratory observation

– Surveillance: The application receiving a select subset of laboratory orders that pertain to public health surveillance

– Payer: The application that providers eligibility and authorization verification



Information ExchangesInformation Exchange Identifier

Exchange Action Exchange Content

A Send Laboratory Order

B Request and Respond Catalogue of Orders

C Request and Respond Patient Health Plan Eligibility Verification Data

D Request and Respond Query and Response for Supporting Information

E Send PseudonymizedLaboratory order



Gaps– HL7v2.5.1 currently supports only Order Placer to Order Filler

Cancel Request. Cancel request from Filler to Placer is required for the Long Term Care setting.

– HL7 2.5.1 does not have enough information for copy-to provider to be specified.

– There is no Implementation Guide Query if catalogue is updated. The construct for sending a Laboratory Catalogue of Orders does not yet exist within HITSP

– Sending supporting information within the HL7 message is currently supported; however a separate query for supporting information is also needed



Gaps– After the order is placed and additional information is deemed

necessary, the lab needs to be able to request additional supporting information for the order. Currently this is handled by telephone or email. HITSP will need to create a construct or Implementation Guide to fill this Gap

– There is currently no Pseudonymization construct for sending laboratory orders to public health.

Overlaps– There are multiple standards and types of laboratory catalogues.


Report from the Provider Perspective Technical Committee

Provider TC Documents – IS01 – Electronic Health Records Laboratory Results Reporting

– IS04 – Emergency Responder

– IS08 – Personalized Healthcare

– IS09 – Consultation and Transfers of Care

– CAP126 – Communicate Lab Results Message

– CAP127 – Communicate Lab Results Document

– CAP99 – Communicate Lab Order Message

– CAP95 – Communicate Order Sets


Report from the Security, Privacy & Infrastructure Domain Technical Committee

1. Review of Products for Action by PanelService Collaborations – SC108, SC110, SC111, SC112, SC113, SC114, SC115, SC116

Capabilities – CAP 143

Constructs – T23, T31, T33, TP13, TP20, TP22, TP50

Technical Note – TN900

2. New Work ProductsCommon Data Transport - TN907

Consumer Preferences – Draft RDSS (in partnership with Consumer Perspective TC)


SPI TC ReportService Collaborations

SC 108 – Access Control

– Editorial cleanup: The interface name “Request Access Control Decision” was not used consistently, and represented C19 and T17 in the same way done in other SC.

– Sequence Tables and Sequence Diagrams updated for consistency and accuracy

SC 110 – Patient Identification Management

– Added Service side interface: “Respond To Patient Management Identification”

– Minor editorial corrections to sequence diagrams and sequence tables


SPI TC ReportGeneral Document Updates

Generalized SCs to make applicable to all ISs, not just EHR-Centric IS developed under the 90-day ARRA Tiger Team period

New Template for Constructs and Capabilities

Editorial Changes from Public Comment and IRT review

Updated informative references and standard version numbers



SC 111 – Knowledge and Vocabulary

– Several editorial changes and corrections

– Edited several figures updated and corrected for consistency andreadability

– Clarification text added to indicate that for all pre-Conditions, the secure communications channel should be selected and implemented if local risk analysis deems it necessary



SC 112 – Healthcare Document Management Data Service

– Added the following Interfaces: Subscribe to Documents in ShareNotify of Documents in ShareCatalog Documents in ShareLocate Documents in Community

– Minor editorial corrections and clarification text

– Updated Topology Diagram and Sequence Diagrams and Tables where needed



SC 113 – Query for Existing Data Service– Completed a few minor editorial updates

SC 114 – Administrative Transport for Health Plan Service– Minor editorial updates to the diagrams to correct typographical

errors and ensure consistency with sequence tables

SC 115 – HL7 Messaging– Editorial updates to text and diagrams to explain Generic HL7

Message Sender and Message Receiver, correct footnotes, correct titles of diagrams

SC 116 – Emergency Message Distribution– Editorial fixes to the diagrams to reflect the sequence given in the

tables


SPI TC ReportCapabilities

CAP143 – Manage Consumer Preferences and Consent

– Update to reflect HITSP Capability Template Version 2.3

– Minor correction to Figure 2-1 (Information Exchange between System Roles)

– Table 2-2 added the appropriate definitions for System Roles

– Other minor editorial changes to add clarity


SPI TC ReportConstructs

T23 – Patient Demographics Query

– Updates to conform to new HITSP Transactions Template

T31 – Document Reliable Interchange

– Editorial changes, updated references to IHE-ITI rev 6.0 or later, and updated reference to IHE-ITI Trial Supplement Cross-enterprise Document Reliable Interchange (XDR) Version 4.0

– Informative reference standards were removed from section 2.3.3 as they did not reflect the underlying standards as specified in the selected IHE profile.

– The descriptive text in the Selected Standard Table 2-11 was updated.

– Changes to conform to the HITSP Transaction Template Version 2.7



T33 – Transfer of Documents on Media– The document has been updated to reflect HITSP Transaction template

version 2.7

– Section 2.3.2 – Selected Standards: Integrating the Healthcare Enterprise (IHE) IT Infrastructure Technical Framework (ITI-TF) Revision 5.0 changed to Revision 6.0 or later.

TP13 – Manage Sharing of Documents– Deprecated XDS.a to be consistent with IHE Deprecation

– Updated Section 2.1.2.3 to explain how nonrepudiation of origin is achieved at moderate level assurance with the Document Integrity Option

– Updated 2.3.2 to remove trial-implementation supplements as they are now formally incorporated into IHE ITI TF Version 6.0

– Updated to include DSUB Option

– Closed Gap 2.1.2.5.1 through a reference to HITSP/C80



TP20 – Access Control

– Included Figure 2-2 Component Relations in Access Control Interfaces illustrating Access Control interfaces

– Adopted American Society for Testing and Materials ASTM International #E1986 -98 (2009) Standard Guide for Information Access Privileges to Health Information

– Updated Health Level Seven (HL7) V3 RBAC, R1-2008, HL7 Version 3 Standard: Role Based Access Control (RBAC) Healthcare Permissions Catalog, Release 1, February 2008 to R2-2009, Release 2, October 2009 pending ANSI acceptance



TP20 – Access Control (cont.)

– Updated to the HITSP Transaction Package Template Version 2.7

– OASIS eXtensible Access Control Markup Language (XACML), February 2005, was incorrectly published as both a selected standard and an informative reference. It is a previously selected standard, and should not have been published as an informative reference. The listing in the informative reference table has been removed

– XSPA-SAML was selected as a normative standard, and should have been placed in the “selected standards” table, but was incorrectly added to the “informative reference” standard table in the November release.

– XSPA-XACML was listed as an informative reference standard



TP20 – Access Control (cont.)– Added explanatory text regarding SOAP and HITSP/TN907 to

Section 2.1

– “Service Consumer” was changed to “Service User” throughout document

– Minor edits to improve clarity in pre-conditions and corrections to text throughout document



TP22 – Patient ID Cross-Referencing– Document modified to incorporate guidance from TN903 (Data Architecture

Technical Note)

– Updated all references to latest IHE ITF Version 6.0 and 2009 Supplement

– Updated data flows, construct contraints and made additional minor editorial changes and corrections

– Updated several PIDs to reflect changes in HITSP C80

– Reformatted to meet new HITSP Construct Template

TP50 – Retrieve Form for Data Capture– Update to latest version of IHE RFD Supplement – August 2009

– Removal of IHE ITI-TF Revision 4.0 from Informative Reference Standards

– Other minor editorial updates, corrections and reformatting to meet new HITSP Construct Template



C164 - Anonymize Newborn Screening Data– New construct developed to address needs from NBS

gaps/extensions document

– Went to public comment in November

– No substantive comments received


SPI TC ReportTechnical Note

TN900 – Security and Privacy Technical Note– Differentiated “entity identity” and “patient identity”

– Integrated NIST SP800-95 threats as part of risk mitigation description

– Described Consent Management Capability (HITSP/CAP143)

– Included additional Anonymize constructs (HITSP/C164, HITSP/C165)

– Included Security and Privacy related Service Collaborations


SPI TC ReportNew Work Products

Common Data Transport – TN907

– New Technical Note developed as an interim deliverable (in lieu of RDSS) in response to the ONC CDT Gaps/Extension Document

– It contains an analysis of the requirements, existing HITSP constructs, and alignment NHIN specifications

– It also contains a discussion of REST vs SOAP and is congruent with the recently published IFR

– Next Steps: Public Comment at end of January to seek input prior to potential development of more Constructs or Capabilities



C165 - Anonymize Long Term Care (new construct)– New construct developed to support a discovered need of the

Long Term Care IS

– Will go to public comment end of January

TP13 – manage Sharing of Documents– Updated to add XCPD (Cross-Community Patient Discovery) and

MPQ (Multi-Patient Queries).

– This is a major change to support Wave 2 IS requirements from Population Perspective TC

– Will go to public comment end of January



Consumer Preferences – Draft RDSS

– Full report provided next


SPI TC ReportThanks

Around 30 documents updated, produced and delivered in the last 60 days

Special thanks to all volunteers, Work Group leaders, and to fellow co-chairs for incredible leadership

Special thank you to Johnathan, Elliot, Sarah for facilitation and technical writing


Final Report from the HITSP Consumer Preferences Tiger TeamCo-Chairs:

Facilitators:

Arlington, VA | January 25, 2010

• Walter G. Suarez, MD, Kaiser Permanente• Mureen Allen, MD, ActiveHealth Management• Johnathan Coleman, Security Risk Solutions, Inc• Michael Nusbaum, MH Nusbaum & Associates, Ltd.• Elliot Sloane, PhD, Center for Healthcare Information Research

and Policy (CHIRP)


Established in August, 2009, as a jointly sponsored activity from SPI-TC and Consumer Perspective TC

Quickly built up a team of over 100 participants with multiple perspectives represented (providers, payers, consumers, federal and state government, SDOs, vendors, associations)

Purpose: address the information exchange requirements and interoperability needs of the ONC Requirements Document on Consumer Preferences

Background


Focus on three areas:

– Review initial categorization of Consumer Preferences from ONC Requirements Document

– Research, identify and document existing and emerging standards for Consumer Preferences

– Review NHIN Factory Specs on Consumer Preferences

Background


Testing new approach to the development of ISs and other HITSP harmonization products

– Work concurrently on RDSS while Requirements Document is finalized

– Interactive communication between ONC, HITSP, NHIN throughout the process

– Speed-up development process and shorten timeline for product completion on the part of HITSP

Background


1 2 3 42. RDSS Start2. RDSS Start

Final RequirementsFinal Requirementsdocument not publisheddocument not publishedyet; Without finalyet; Without finaldocument, RDSSdocument, RDSScannot be finalizedcannot be finalized

4. Publication of RDSS4. Publication of RDSS

1.1. Tiger TeamTiger TeamStartStart

3.3. DRAFTDRAFT RDSS CompletedRDSS Completed


Overview of Consumer PreferencesPer ONC document:

For the purposes of this document, the term “consumer preferences” is used to collectively represent several inter-related capabilities including, but not limited to:

– The ability for a consumer to define permissions for who is permitted to access information in their EHR and under what circumstances this access is appropriate,

– The ability for a consumer to express preferences for how and under what circumstances their health information would or would not be made available by their healthcare providers,

– The ability for a consumer to authorize the release of their health information to another provider or third party; and

– The ability to establish various types of consumer preferences including but not limited to consents, advance directives and other potential types outlined in the Dataset Considerations section of the document.


Consumer expressions of choices, desires or directives in two general areas:

1. Health information privacy (consents or authorizations)Establishing access restrictions and management parameters on health information

Defining privacy preference “conditionants” including:By type of information (all data, segmentation of data)

By role and criteria based access, including type of encounter, embargoed records (VIP, legal restrictions)

By time (start, end, duration)

By level of participation (opt-in, opt-out, with or without additional classifications, with or without additional granularity)

By purpose of use

Overview of Consumer Preferences


2. Content, Communication and RepresentationStatus and/or designation, including advanced directives, DNR orders, healthcare proxies, living wills, medical surrogates, access to family members

Care or associated services needs and communication needs, including appointment reminders, lab results

Comfort needs, including non-medical dietary restrictions, language needs, cultural needs, clergy preferences

Overview of Consumer Preferences


Original Perspectives and Scenarios

Perspectives/Roles

Consumer: Any recipient or legal proxy of a recipient of healthcare who wishes to create preferences regarding aspects of their care and how their health-related information (HRI) is accessed or shared.

Primary Receiving Organization: Any organization (provider, information exchange or other information recipient) who receives and may act on or manage a consumer preference and its related health information.

Secondary Receiving Organization: Any organization (provider, information exchange or other information recipient) who receives from another organization and may act on or manage a consumer preference and its related health information.


Original Perspectives and Scenarios

ScenariosThe Process Diagram explains business processes surrounding consumer preferences including descriptions of events and actions. The Diagram is broken into two scenarios and 29 events

Scenario 1: Creation of a Preference – The process by which the consumer creates a preference by expressing their preference an organization.

Scenario 2: Preference Management: Application, Exchange and Replacement – The process by which the an organization identifies and/or retrieves, applies, and exchanges a consumer’s preference to another organization.


CP-TT - Approaches to Identifying Existing and Emerging Standards

Considerations for Identifying Standards

What standards are we trying to identify?Privacy-related standards

Content-related standards

‘Universal’ standards (applicable to both)

Key Actions and Information Exchange ComponentsConsumer: Express, Amend, Replace, Request Exchange, Request Audit

Receiver/Requester/Submitter: Create, Transmit, View, Store, Apply, Amend, Replace Transmit Update, Reconcile Conflicting Preferences, Acknowledge Receipt of Preference (or Update), Maintain Audit Log of Preferences, Classify Data


Considerations for Privacy PreferencesWhat - information is to be allowed/restricted (all, some, certain)

By whom - who is the entity that holds the data and to whom the consent will apply

To whom - the entity/individual what will receive or will access the information

For what purpose - will the information be allowed to be collected, accessed, used or disclosed

When - a time factor affecting the consent

How - the methods by which the collection, access, use or disclosure may be done (i.e. HIE, PHR, etc)

Opt-in/Opt-out - the goal of this HITSP Workgroup was not to replace the commonly referred to “Opt-in/Opt-out,” but to further clarify it



Considerations for Content Preferences

Many different ‘content’ type options

No easily definable categorization of each content type

Most exist in legal (paper-based) documents but not in electronic form or defined standards

Most depend on federal and/or state regulatory specs/guidelines and have other legal ramifications/considerations

All require the ‘intervention’ of a human at the end of the process to ultimately complete the execution (hard to automate process end-to-end)



Consumer Preferences Tiger Team Work

Extensive review of draft Requirements document; provided

detailed comments including

– Refinement of Scenarios (break-out of two original scenarios into sub-

scenarios)

– Refinement of Process Diagrams (based on changes to original

scenarios)

– Out-of-scope clarifications (consumer education, reconciling

preferences)

Organized the TT into two Workgroups: Privacy Preferences and

Content Preferences


Consumer Preferences Tiger Team Work

Initial joint discussions to understand new RDSS template, agreeon refinements to original scenarios, process diagrams, information exchange flows

Each workgroup met weekly to begin documenting key definitional issues around respective preferences

Content preference workgroup had larger initial task, as varioustypes of content preferences not well defined or categorized

Each workgroup began completing respective sections of RDSS

Workgroups started with an environmental scan of activities related to consumer preferences


Environmental Scan – Current Consumer Preference Activities

HIT Policy Committee work (and newly created Privacy and Security Workgroup) and HIT Standards Committee work (particularly the Privacy and Security Workgroup) regarding recommendations on Meaningful Use, Standards and Certification Criteria

Reports from ONC related to privacy policies across states (released January 8, 2010)

New/upcoming ONC Whitepapers on CPs, Segmentation of Health Information



HL7: CBCC, Security, SOA (PASS) Workgroups

Composite Privacy Consent Directive Domain Analysis Model (DAM)

Security Domain Analysis Model (DAM)

Proposal to develop a CDA document for consent directive

Several codesets related to Consumer Preferences

PASS Activities – creating the service interfaces so CPs can be turned into Access Control decisions


Other Standards Efforts

– ISO, ASTM work on coding areas such as Purpose of Use

– LOINC – work on new codes related to privacy

Evaluating work being done by in other countries

Canada

EU



Evaluate NHIN requirements related to consumer preferences

Build on HITSP Products

– TP30 / TP20

– CAP143

– C83

NHIN and HITSP


RDSS Development


RDSS DevelopmentThe RDSS document defines the information exchangerequirements involved in the creation, management, execution and exchange of Consumer Preferences.

The document also provides detailed mapping of scenarios, systems descriptions, capabilities being used, orchestration of these capabilities, and their existing gaps.

Finally, the document provides a complete mapping of information exchange requirements to functional requirements based on the reference document and the need for new exchange content, exchange actions, data requirements and new or updated capabilities and constructs.


RDSS Development

The RDSS document describe the content and exchange requirements of two distinct types of Consumer Preferences:

–Privacy Preferences: consumer’s desire to grant or deny access to some or all of their healthcare-related information, to some defined set of users, for some defined set of purposes, for some defined time period.


RDSS Development

–Content Preferences, which describe the consumer’s desire about how they wish to be treated by their care givers. These preferences include such items as, but not limited to:

– Advance Directives

– Audio Preference

– Cultural Preferences

– Dietary Preference

– Language Preference

– Do Not Resuscitate (DNR)

– Confidential Communication Preference

– Disposition of deceased human body/organs

– Live organ donation

– Living Wills

– Medical Home designation

– Spiritual Preference

– Vision Preference

– Other Preferences

– Funeral arrangements (disposition of body)

– Health Care Proxy/Medical Surrogate


RDSS Development – Refinement of Scenarios


RDSS Development – Capabilities Used


RDSS Development

Section 4 – Initial set of capability gaps identified and recommended resolution provided

Section 5 – Appendix

–Harmonization request traceability table provided (back to the original Requirements Document from ONC)

–Detailed identification of all new exchange content needed for both privacy and content preferences


Next Steps

Draft RDSS delivered to IRT for internal editorial and quality review

IRT comments addressed and final draft delivered to HITSP program management (January 22, 2010)

Draft RDSS will not go out for public comment

– No Final Requirements Document out yet

– Would not be appropriate to request comments on a draft RDSS that is based on a draft Requirements Document

Open work item for future work

– Once final Requirements Document is published, draft RDSS will need to be harmonized with Requirements Document, and then harmonization process can proceed (development of IS, constructs, etc)


Report from the Care Management & Health Records Domain Technical Committee

Restarted efforts after IS 107 (EHR Centric IS) and TN903 Data Architecture was completed (August 2009)

Goals Included

Address the 2009 AHIC Use Case gaps and extensions

Modification of existing constructs to better support ARRA and Meaningful Use

Construct maintenance to support HITSP template updates

Work was broken up into three wavesWave 1 completed

Wave 2 work analysis begun


CM&HR Wave 1 ActivitiesCAP - 119 Communicate Structured Document

Changes for Clinical Notes Extension

Use of C83 based Content Modules

C83 - CDA Content Modules

Support for encodings using HITECH specified vocabularies

Additions to support Wave 1 Constructs for Clinical Notes Extension and Population Newborn Screening

C80 – Clinical Document and Message Vocabulary

Extended Value sets to support Vocabularies specified in Meaningful Use

Inclusion of jointly developed National Library of Medicine Vocabularies for starter set of Laboratory Order and Newborn Screening Laboratory Orders

Added Vocabulary to support Wave 1 and Wave 2 work


CM&HR Wave 1 Activities

C152 – Labor and Delivery SummarySupport for Maternal and Child Health Use Case

Support for Newborn Screening Use Case

Ability to support as a Clinical Note

C161 – Antepartum RecordSupport for Maternal and Child Health Use Case

Ability to support as a Clinical Note

C163 – Laboratory Order MessageSupport for the General Laboratory Order Use Case


CM&HR Wave 1 Maintenance

C70 – Immunization Query and ResponseUpdated to support Data Architecture TN903

Identification of HITSP data elements (C154), mapping and constraints

C72 – Immunization MessageUpdated to support Data Architecture TN903

Identification of HITSP data elements (C154), mapping and constraints

C78 – Immunization DocumentUpdated to support Data Architecture TN903

Identification of HITSP data elements (C154)

Addition of templateIds and constraints


Report from the Care Management & Health Records Domain Technical Committee

Published Constructs for public comment (November-December, 2009)

Completed resolution/disposition of over 150 Laboratory Order Message comments by January 4

Completed resolution/disposition of 118 comments for all other CM&HR Constructs by December 20




CM&HR Wave 2 (Work in progress)

C148 – EMS Transfers of Care

Address Pre-hospital Care gap for EHR Emergency Responder Use Case

C162 – Plan of Care

Support Clinical Notes Extension and Gaps

Addressed Gaps in Consults and Transfers of Care Use Case

C166 – Operative Note

Support Clinical Notes Extensions and Gaps

C168 – Long Term Care and Post Acute Assessment

Based on HL7 Implementation Guide: CDA Framework for Questionnaire Assessments

Support Clinical Notes Extensions and Gaps


CM&HR Wave 2 Maintenance

C28 – Emergency Care SummaryUpdated to support Data Architecture TN903

Expanded Construct from direct IHE reference to use of HITSP/C83 cdaSection

Addition of templateIds and constraints


Report from the Data Architecture Tiger Team

Tiger Team work started as part of ARRA Initiative

Membership: 160 joined the TT; added a large number of new members to HITSP

Goals of Data Architecture Tiger TeamProvide Data Architecture Design for Use of Data Element, Value Sets and Templates Used Within HITSP

Ensure Data Element Consistency Across HITSP Specification

Develop Data Architecture Technical Note – TN903

Support Meta-Data Registries

Address CMHR/DA Public Comments


Published TN903 for public comment (August, 2009)

On-going effort to convert HITSP Transaction Packages, Transactionsand Components to conform to TN903. define HITSP Data Elements and resolve HITSP Data Element inconsistencies

Creation of C154/HITSP Data Dictionary and re-alignment of C83/HITSP cda Sections and C80/Clinical Document and Message Terminology

Prepared draft conversions of HL7 related Constructs (September-October, 2009) – Details provided in CM&HR Report

TP22 - Patient ID Cross-Referencing

T23 - Patient Demographics Query

C70 – Immunization Query and Response

C72 – Immunization Message

C78 – Immunization Document



Published Constructs for public comment (November-December, 2009)

Received 9 comments; completed resolution/disposition of comments by December 20

Completed HITSP Inspectors Testing Process (December, 2009)





Continued focus on conversion of ASCX12/NCPDP Administrative and Financial Domain Technical Committee’s Constructs

Update of C154/HITSP Data Dictionary

Prepared draft conversions of ASC X12/NCPDP related Constructs (September 2009 – January 2010)

T40 – Patient Heath Plan Eligibility Verification

T68 - Patient Heath Plan Authorization Request and Response

T79 – Pharmacy to Health Plan Authorization Request and Response

TP43 – Medication Orders

TP46 – Medication Formulary and Benefit Information



Report from the Administrative and Financial Domain Technical Committee

Gaps and Extensions work for 2009 included

– Identifying standards for use in consumer/provider appointment scheduling

– Expanding existing prior-authorization transaction functionality to include consumers

Other work

– Updated existing constructs

– Assumed ownership of Capabilities developed by the Capabilities Tiger Team


Scheduling Capability

Workgroup defined requirements: Jan – Apr 2009

Drafted Capability (HITSP/CAP93): Sep – Oct 2009

Published CAP93 for public comment in Nov 2009

Dispositioned comments and refined the capability in Dec 2009 – Jan 2010

CAP 93 is scheduled for release by HITSP on January 29


Scheduling Capability (continued)

Standards selected:HL7 v2.5.1 Chapter 10: Scheduling

HL7 Version 3 Standard: Scheduling, Release 1

Core functions include:Requesting an appointment

Rescheduling an appointment

Appointment modification

Appointment cancellation


Scheduling Capability (continued)

Identified GapLack of an implementation guide for HL7 v2 Scheduling

Gap ResolutionHL7 has initiated a project to create an implementation guide

Estimate that it will require up to 1 year to complete the implementation guide work


Prior Authorization Gaps and Extensions

Workgroup defined requirements: Jan – Apr 2009

Capability Drafted (HITSP/CAP141): Aug – Sep 2009

Published CAP141 for public comment in Oct 2009

Dispositioned comments and refined the capability in Nov – Dec 2009


Prior Authorization (continued)

CAP 141 UtilizesHITSP/T68 – Patient Health Plan Authorization Request and Response

HITSP/T79 – Pharmacy to Health Plan Authorization Request and Response

HITSP/SC114 – Administrative Transport to Health Plan



Core functions include:Request for Health Plan to authorize certain healthcare services

Health Plan Response for healthcare services

Request for Health Plan to authorize certain pharmacy products or services

Health Plan Response for pharmacy products or services



Gap Description Required Standard SDO Expected Availability

Consumer requests a Provider list

ASC X12 274 transaction is not currently designed to allow consumers to make this inquiry

ASC X12 To be determined

Consumer Request Eligibility Benefits

ASC X12 270 not currently designed to interact with consumers


Identified Gaps for CAP 141




Consumer sends Prior Auth information to a Payer or Provider system from their PHR or similar system

There are no current standards available today that include the PHR system. This requires a change to ASC X12 278


Consumer uses this PHR or similar system to communicate prior-authorization information to a provider or payer system

No standards available today that includes the PHR system. Change needed to ASC X12 278 to support medical history





Provider send Prior Auth request for information to a Payer about non-patient specific Prior Auth information

Neither the X12 278 nor NCPDP Formulary and Benefit real-time transactions support this function today

ASC X12

NCPDP

To be determined

NCPDP unable to ascertain a business needs for the exchange


Prior Authorization (continued)Gap Description Required Standard SDO Expected

AvailabilityQuery for patient-specific prior-authorization criteria

The ASC X12 271 eligibility transaction today cannot provide information about the prior-authorization criteria. It also may not provide alternative treatments


Respond to non patient-specific eligibility request by a consumer or provider for specific service, treatment, therapy, etc. or a list of services

ASC X12 271 does not provide eligible benefit coverage for non-patient specific procedures or therapies




AvailabilityRespond to non patient-specific eligibility request by a consumer or provider for specific service, treatment, therapy, etc. or a list of services

NCPDP not currently designed to interact with a consumer

NCPDP NCPDP unable to ascertain a current business need for the exchange



AvailabilityRespond to patient-specific prior-authorization or eligibility queries from consumers

ASC X12 and NCPDP do not support the consumer

ASC X12

NCPDP

To Be DeterminedNCPDP unable to ascertain a current business need for the exchange



AvailabilityParticularly in the event of a rejection, a payer may need the ability to communicate an explanation for a prior-authorization decision as well as to communicate information on alternative treatment options or an Advanced Beneficiary Notification (ABN)

The gap is being able to communicate alternate treatment options for medical benefits

ASC X12 To Be Determined


Updated Constructs

HITSP/T40 – Patient Health Plan Eligibility Verification Transaction

Corrected a typo where 004010X092A1 was incorrectly referenced as 004010X92A1

Global changes made to be consistent with X12 nomenclature when that information speaks directly about X12 data elements and X12 structures.

Moved the CAQH CORE constraints to become message constraints

Split what had become Table 2-4 into two tables, one for the eligibility request and another for the response, Table 2-5


Updated Constructs

HITSP/T68 – Patient Health Plan Authorization Request and Response Transaction

Updated to the latest HITSP Transaction template

Corrected a typo where 004010X094A1 was incorrectly referenced as 004010X94A1

Revised wording in Section 1.1 and 2.1 to add clarity

Updated various constraint statements in Tables 2-4 and 2-5


Updated Constructs

HITSP/T79 – Pharmacy to Health Plan Authorization Request and Response

Updated to the latest HITSP Transaction template

Modified to reflect the HITSP/TN903 Data Architecture approach

Added Section 2.1 per HITSP/TN903

Duplicate constraints removed from Table 2-1

Added message constraints per HITSP/TN903 format

Added a constraints reference appendix


Capability 140 – Communicate Benefits and Eligibility

Assumed ownership after this capability was drafted by the Capabilities Tiger Team

CAP 140 UtilizesHITSP/T40 – Patient Generic Health Plan Eligibility Verification

HITSP/TP46 – Medication Formulary and Benefits Information

HITSP/SC114 – Administrative Transport to Health Plan


Capability 140 – Communicate Benefits and Eligibility (continued)

Core functions include:Request for Health Plan Clinician care benefits verification Health Plan Clinician care benefits responseRequest for Health Plan pharmacy benefits verificationHealth Plan Response for pharmacy benefits Request for Medication Formulary and Benefits verificationHealth Plan or intermediary response for Medication Formulary and Benefits


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